Special Feature

Health Biz India July 2014 42

By: Dr. AK Khandelwal

Medical literature reveals that in-patient suicide

rate among non psychiatric patients is 5-15 per 1,00,000 admissions and 100-400 per 1,00,000 admissions in psychiatric patient. Joint Commission International on accreditation of healthcare organisations also reported that in-patient suicide occupies the second position among all 12 sentinel events.

However, there is a paucity of studies on suicide in non-psychiatric patients. The problem of suicides in

such patients is less common and hence physicians and the hospital staff have less experience in dealing with this problem.

As per reports, around 51 per cent of psychiatrists report of having had a patient who committed suicide. However, having similar predictability becomes difficult in non-psychiatric patients.

These days, post-suicide lawsuits account for the largest number of malpractice suits against psychiatrists, a psychiatrist’s risk of being sued for malpractice is still quite low though. Western literature reveals that even when sued,

clinicians win up to 80 per cent of the cases.

Suicidal methodsThey can be non-violent or violent. However, studies suggest that non-psychiatric patients often resort to violent methods, like: • Jumpingfromaheightin

multi-storied hospitals or wards

•Hanginginsidethehospitalward or in the premises

• Consumptionofpoisonoussubstances/drugs or self injection overdose

• Self-mutilationbyeasily-available objects like fruit cutting knife, glass or bottles etc.Risk factors for suicide

include: previously attempted suicide; recent suicide attempt; suicidal thoughts or behaviors; family history of suicide or psychiatric illness; on antidepressants; physical health problems, including central nervous system disorders such as traumatic brain injury; diagnosis of delirium or dementia; chronic pain or intense acute pain; poor prognosis or prospect of certain death; social stressors such as financial strain, unemployment or loss of financial independence; disability; trauma; divorce or other relationship problems; hopelessness; substance abuse

Handling a Post-suicide ScenarioHandling a post-suicide lawsuit is perhaps the worst nightmare of a hospital administrator

Special Feature

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w.he

alth

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Health Biz India July 2014 43

like alcohol, drugs, etc.

Strategies for suicide prevention In order to effectively reduce the risk of suicide in the medical/surgical and emergency department settings, organisations need to identify patients at risk of suicide and then intervene to prevent suicides in those patients identified as ‘at risk’.

Recommendations:• Regular(everythree

years) staff training in risk management

• In-patientswithseveremental illness and a history of self-harm or violence should receive the highest level of care under the care programme approach

• Individualcareplansshouldspecify action to be taken if a patient fails to adhere to treatment or to attend appointments

• Promptaccesstoservicesfor people in crisis and their families

• Assertiveoutreachteamstoprevent loss of contact with vulnerable and high-risk

patients• Atypicalantipsychotic

drugs to be available for all patients with severe mental illness prescribed typicals who are non-adherent because of drug side-effects

• Localstrategiesfordualdiagnosis that include training in the management of substance misuse services and employment of staff with specific responsibility for developing the local service

• Removalorcoveringofalllikely ligature points in in-patient wards

• Localarrangementsforinformation-sharing with criminal justice agencies

• Policyensuringpost-incidentmultidisciplinary case review

and provision of information to the patient’s family

Liability of a hospitalIt is not uncommon to see a few patients committing suicide in hospital premises. Hence, a hospital should be prepared for such a scenario. Hence, what would be the responsibility and

• Isolatethebody(butdonot

disturbit)

• Contactseniornursingand

medical staff

• Contactthefamily

• Contactthepolice

• Documentthecircumstances

of the suicide and all the

actions carried out

• Holdabriefstaffmeetingto

disseminate information

• Informhospitalmanagement

• Meetwithfamily

• Holdabriefmeetingwith

patients to disseminate

information

• Conveysympathiestothe

family(e.g.card,letter,

attendanceatfuneral)

• PerformRootCauseAnalysis

• Educatestaffaboutfindings

andcorrectivemeasures

taken

What to do when a patient commits suicide

Myths about SuicidePatientswhorepeatedlymakesuicidethreatsdon’treallywanttodie

Discussingsuicidemay“givethepatientideas”

Depression is a normal reaction to medical illness

A history of prior attempts means that the patient is not serious

Suicidality and depression will simply fade away with time

Wanting to die is common in the seriously ill patient

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Health Biz India July 2014 44

liability of a hospital manager in such situations?

The hospital can be held responsible only if it is proved that the person was under absolute care and protection of hospital staff. It is absolutely correct in cases where visitors are prohibited and hospital staff has the sole authority over the patient. In situations where a person in under dual responsibility of hospital staff as well as of relatives, it is very difficult to decide the issue.

Where an in-patient’s suicidal tendencies are known and the risk of harm can be identified through the exercise of professional medical judgment, the failure to take measures to prevent the harm may constitute malpractice. The care taker duty to prevent suicide is premised upon his special training or experiences and his consequence ability to recognise suicidal tendencies in person under his care.

Accordingly, many jurisdictions have imposed liability for suicide attempts where a patient has surrendered himself to the custody and care of a psychiatric hospital or mental institution as an inpatient. Conversely, courts are much more hesitant to impose liability upon a psychiatrist for a suicide attempt on an outpatient basis. Non-psychiatric physicians are not trained to identify suicidal tendencies and cannot be held liable.Therefore, this comment proposes that liability for causing suicide is rarely appropriate, not only because most suicides are not caused by another person, but because the act of suicide is usually a voluntary one for which another person cannot be held

liable; but, liability for failing to prevent suicide is proper when a person or entity in a special relationship with a suicidal person breaches its duty to prevent a foreseeable suicide.

In conclusionSuicideinhospitalpremisesis relatively rare but clinically quite common. It is therefore important that clinicians are up-to-date with suicide risk assessment and prevention strategies, the difficulties of predicting and preventing suicides, and their trust’s responsibilities in relation

to their patients. Hospital management should ensure that strategies for suicide prevention are integrated in the hospital risk management programme. Once a suicide occurs, appropriate measures should be taken as mentioned to prevent both immediate and long term complications.

Disclaimer: This article should be treated only as a reading material and readers are advised to seek professional assistance of a medico-legal expert in case of being faced with the above-mentioned scenario.

About the author Dr. Ashok Kumar Khandelwal is the MedicalDirector,Anandaloke Hospital & NeurosciencesCentre,West Bengal. He is a trained Assessor from the National Accreditation Board for Hospital and Health CareProvider(NABH).He carries around two decades of experience in the hospital industry and 15 years of experience as a hospital administrator.